Patient History: The Integral Part Of The Medical Report

PATIENT HISTORY: THE INTEGRAL PART OF THE MEDICAL REPORT

It is true 'Listen to your patient & they tell you the diagnosis’

Modern medicine practices are ethically bound to documentation of the data generated during patient’s treatment. Documenting complete information of the illness and treatment has generated enormous medical records. It can be history record/initial visit record, admission form, operative report, follow-up visit, therapy note, pharmacy note, discharge note or death report also. In all these reports, patient’s history is one of the essential element which is captured.

Patient History:

This term can be defined as the past information of the patient which is medically important gathered mainly by asking specific questions to the patient or concerned people. This has proved to be the evidence based approach in differential diagnosis. History taking and documenting is an art. History is normally collected by nurse or the treating physician every time when the patient approaches the doctor for any new complaint mainly.

History of the patient is collected under various subheading, it has its own importance in the treating the illness:

1. History of Present Illness: Current complaints, events or incidences with relevant details are the part of history of present illness. The details include description of the injury, complaints, examination, finding, investigations and treatment rendered.
2. Past Medical History: It includes significant past diseases, illness, trauma, accidents or complications the patient has suffered in the past.
3. Past Surgical History: Past surgeries with complications if any are mentioned under this heading.
4. Family History: This section includes medical history of the parents, siblings, children or blood relatives but never of spouse or in-laws.
5.  Medicine/Drug History: Current medications with dosage and medications taken in the past are listed under this heading.
6. Allergies: Any allergies to drugs, food, animal, dust, pollen or seasonal are mentioned with effects seen on the patient.
7. Social History: This section includes patient’s habits like smoking, drinking, drug abuse, it also includes information on marital status, occupation, pets, habits and accommodation.
8. Systemic Assessment: Under this subheading all the other complaints related to body systems are included.
9. Psychiatric History: This is frequently lengthy and in depth history of patient’s emotional status.
10. Immunization History: Immunizations from birth and yearly immunization dates are mentioned under this history.
11. Diagnostic Studies: The review of the various diagnostic studies carried out for above mentioned problems are mentioned under this heading.

‘It is said that a good history is one which reveals the patient’s ideas, concerns and expectations as well as any accompanying diagnosis’.

Inhibition in collecting the good and relevant medical history could be due to inability of the patient to communicate, improper doctor-patient relationship, unwillingness of the patient to disclose certain information.

Computer Assisted History Taking:

Computer technology started in 1960. It allows easy collection and portability of the medical data saving money and paper- known as electronic medical records.

Advantages of The Medical History in Medical Data Processing:

Accurate medical history is an advantage for any care giver while treating the patient. There are many advantages of accurate history data in various other aspects related to medical field:

1. Insurance: In settling the claim, medical history proves very helpful. Assessing the history from medical data decides the flow of the claim.
2. Investigational Aspect: Patient history in medical records plays and key role in investigational aspects of the legal and criminal cases.
3. Recruitments: History of the patient is an integral part of the documents required for recruitment.
4. Pharmacogenomics: To study genome in drug response patient’s history is a vital data that has been gattered. It is studied to better understand the biology behind diseases and drug response phenotypes.

Conclusion:

ITCube understands the widely spread importance of medical history. Handling all types of medical records and accurately correlating the medical history and summarizing it, which enables the review of those records easy and less time consuming. ITCube caters this services to various litigation firms and TPAs, which indeed helped them to focus more on the core business as we provide the very precise, accurate and handy summaries saving their time to review the documents.

To know more about ITCube services you can mail us on info@itcubebpo.com or you can call us on +1 (614) 434-2376.